Pain-related fear is typically associated with avoidance behavior and pain-related disability in youth with chronic pain. Youth with elevated pain-related fear have attenuated treatment responses; thus, targeted treatment is highly warranted. Evidence supporting graded in vivo exposure treatment (GET) for adults with chronic pain is considerable, but just emerging for youth. The current investigation represents the first sequential replicated and randomized single-case experimental phase design with multiple measures evaluating GET for youth with chronic pain, entitled GET Living. A cohort of 27 youth (81% female) with mixed chronic pain completed GET Living. For each participant, a no-treatment randomized baseline period was compared with GET Living and 3- and 6-month follow-ups. Daily changes in primary outcomes fear and avoidance and secondary outcomes pain catastrophizing, pain intensity, and pain acceptance were assessed using electronic diaries and subjected to descriptive and model-based inference analyses. Based on individual effect size calculations, a third of participants significantly improved by the end of treatment on fear, avoidance, and pain acceptance. By follow-up, over 80% of participants had improved across all primary and secondary outcomes. Model-based inference analysis results to examine the series of replicated cases were generally consistent. Improvements during GET Living was superior to the no-treatment randomized baseline period for avoidance, pain acceptance, and pain intensity, whereas fear and pain catastrophizing did not improve. All 5 outcomes emerged as significantly improved at 3- and 6-month follow-ups. The results of this replicated single-case experimental phase design support the effectiveness of graded exposure for youth with chronic pain and elevated pain-related fear avoidance.

The evaluation of brain changes to a specific pain condition in pediatric and adult patients allows for insights into potential mechanisms of pain chronicity and possibly long‐term brain changes. Here we focused on the primary somatosensory system (SS) involved in pain processing, namely the ventroposterolateral thalamus (VPL) and the primary somatosensory cortex (SI). We evaluated, using MRI, three specific processes: (a) somatotopy of changes in the SS for different pain origins (viz., foot vs. arm); (b) differences in acute (ankle sprain versus complex regional pain syndrome‐CRPS); and (c) differences of the effects of CRPS on SS in pediatric versus adult patients. In all cases, age‐ and sex‐matched individuals were used as controls. Our results suggest a shift in concurrent gray matter density (GMD) and resting functional connectivity strengths (rFC) across pediatric and adult CRPS with (a) differential patterns of GMD (VPL) and rFC (SI) on SS in pediatric vs. adult patterns that are consistent with upper and lower limb somatotopical organization; and (b) widespread GMD alterations in pediatric CRPS from sensory, emotional and descending modulatory processes to more confined sensory‐emotional changes in adult CRPS and rFC patterns from sensory‐sensory alterations in pediatric populations to a sensory‐emotional change in adult populations. These results support the idea that pediatric and adult CRPS are differentially represented and may reflect underlying differences in pain chronification across age groups that may contribute to the well‐known differences between child and adult pain vulnerability and resilience.

Approximately 1.7 million youth suffer from debilitating chronic pain in the US alone, conferring risk of continued pain in adulthood. Aberrations in threat–safety (T–S) discrimination are proposed to contribute to pain chronicity in adults and youth by interacting with pain-related distress. Yet, few studies have examined the neural circuitry underlying T–S discrimination in patients with chronic pain or how T–S discrimination relates to pain-related distress. In this study, 91 adolescents (10-24 years; 78 females) including 30 chronic pain patients with high pain-related distress, 29 chronic pain patients with low pain-related distress, and 32 healthy peers without chronic pain completed a developmentally appropriate T–S learning paradigm. We measured self-reported fear, psychophysiology (skin conductance response), and functional magnetic resonance imaging responses (N = 72 after functional magnetic resonance imaging exclusions). After controlling for age and anxiety symptoms, patients with high pain-related distress showed altered self-reported fear and frontolimbic activity in response to learned threat and safety cues compared with both patients with low pain-related distress and healthy controls. Specifically, adolescent patients with high pain-related distress reported elevated fear and showed elevated limbic (hippocampus and amygdala) activation in response to a learned threat cue (CS+). In addition, they showed decreased frontal (vmPFC) activation and aberrant frontolimbic connectivity in response to a learned safety cue (CS−). Patients with low pain-related distress and healthy controls appeared strikingly similar across brain and behavior. These findings indicate that altered T–S discrimination, mediated by frontolimbic activation and connectivity, may be one mechanism maintaining pain chronicity in adolescents with high levels of pain-related distress.

The study examined the relationships between social anxiety (SA), generalized anxiety (GA), and depression with racial microaggressions and internalized racism (IR) among Black young adults. Given SA's core features, we expected it to have a unique association with IR, and to moderate the connection between racial microaggressions and IR. Participants were 182 Black university students who completed measures of SA, GA, depressive symptoms, racial microaggressions, and IR. Linear regression models indicated that IR was a significant predictor of SA, but not GA or depression. Racial microaggressions were only positively associated with depressive symptoms. SA and racial microaggressions each predicted IR, but no interaction was found. Black young adults with elevated concerns of others' evaluation may be more prone to accepting negative stereotypes about one's racial group.

Objective Some children with chronic pain struggle with fear of pain, avoidance behaviors, and associated disability; however, movement adaptations in the context of chronic pain in childhood is virtually unknown. Variability in adaptive movement responses previously observed between individuals might be largely explained by the presence of problematic psychological drivers (eg, fear, avoidance). The goals of this study were to (1) quantify the variability of gait and (2) examine relationships among pain, fear, avoidance, function, perceived and objective, and gait variability. Methods This study used a cross-sectional design. Eligible patients were between 8 and 17 years of age and had musculoskeletal, neuropathic, or headache pain that was not due to acute trauma (eg, active sprain) or any specific or systemic disease. Participants completed the Numeric Pain Rating Scale (NPRS), Fear of Pain Questionnaire (FOPQ), Functional Disability Inventory (FDI), and 6-Minute Walk Test (6MWT) and received kinematic gait analysis. Relationships were analyzed among these measures, and the self-report and functional measures were examined to determine whether they predicted gait variability (GaitSD). Results The 16 participants who were evaluated (13.8 [SD = 2.2] years of age; 13 female) had high NPRS scores (6.2 [SD = 2.1]), FOPQ-Fear scores (25.9 [SD = 12.1]), FOPQ-Avoidance scores (22.8 [SD = 10.2], and FDI scores (28.6 [SD = 9.4]) and low 6-Minute Walk Test (6MWT) distance (437.1 m [SD = 144.6]). Participants had greater GaitSD than age-predicted norms. Fear was related to self-selected GaitSD, and avoidance was related to both self-selected and standardized GaitSD. Avoidance predicted 43% and 47% of the variability in self-selected and standardized GaitSD, respectively. Conclusions Gait variability was significantly related to both fear of pain and avoidance behaviors, suggesting the interplay of these psychological drivers with movement. FOPQ-Avoidance was robust in accounting for GaitSD. Impact This study offers preliminary evidence in understanding movement adaptations associated with adolescents with chronic pain. They may lend to more directed interventions.

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